Spinal cord injury. What are the consequences of a spinal cord injury, and how to return to a full life? Spinal cord injury at the lumbar level

8735 0

Closed injuries of the spine and spinal cord are divided into three groups:

1) damage to the spine without impaired function of the spinal cord;

2) injuries of the spine, accompanied by a violation of the conduction function of the spinal cord;

3) closed injuries of the spinal cord without damage to the spine.

Spinal injuries occur in the form of fractures of the bodies, arches, processes; dislocations, fracture-dislocations; ruptures of the ligamentous apparatus, damage to the intervertebral discs. Damage to the spinal cord can be in the form of compression of the brain and its roots by an epidural hematoma or bone fragments, concussion or contusion of the medulla, rupture of the spinal cord and its roots, subarachnoid hemorrhage and hemorrhage into the medulla (hematomyelia).

Spinal cord contusion is characterized by dysfunction of the conduction tracts and is manifested by paralysis and loss of sensation below the level of damage, urinary retention and defecation. All phenomena develop immediately after the injury and last for 3-4 weeks. Pneumonia, bedsores, ascending cystopyelonephritis and urosepsis may develop during this period.

Spinal cord compression may be sharp (occurs at the time of injury) early (hours or days after injury) and late (months or years after injury).

Localization compressions are distinguished: rear (shackle of a broken vertebrae, epidural hematoma, torn ligamentum flavum), front (body of a broken or displaced vertebra, prolapsed intervertebral disc), internal (cerebral edema, intracerebral hematoma, detritus in the focus of softening).

The pressure may be with complete obstruction CSF pathways and conduction functions of the spinal cord, with partial obstruction liquor-conducting pathways, and by the nature of development - acutely progressive and chronic.

Diagnosis of spinal cord compression syndrome is based on neurological examination data, survey spondylograms and special research methods, including assessment of the patency of the subarachnoid space during lumbar puncture with liquorodynamic tests, positive myelography with water-soluble contrast agents, or pneumomyelography. The syndrome of spinal cord compression is characterized by a block of the subarachnoid space, an increase in neurological disorders. The ascending edema is especially dangerous in case of injury of the cervical spinal cord.

When the spinal cord is compressed by the posterior structures of the vertebrae, decompressive laminectomy of 2-3 arches is used. The timing of its implementation in case of closed injuries of the spine:

• emergency laminectomy - within the first 48 hours after injury;
• early laminectomy - the first week after the injury;
• late laminectomy - 2-4 weeks.

When the anterior structures of the spinal cord are compressed by bone fragments displaced into the lumen of the spinal canal, damaged intervertebral discs, an operation is used - anterior decompression of the spinal cord (removal of bone fragments and destroyed intervertebral discs by anterior access) followed by anterior corporodesis with a bone autograft.

Vertebral fractures without damage to the spinal cord are treated either conservatively: lumbar and thoracic - stretching with straps for the axillary areas on a bed with a shield, using rollers for repositioning the vertebrae in bed; cervical region - by skeletal traction for the parietal tubercles and zygomatic bones, or surgically, in order to restore the configuration of the spinal canal and stabilize the spine: vertebrae are repositioned, bone fragments are removed and the spine is fixed with metal structures.

In case of spinal cord injuries without damage to the spine, conservative treatment is performed.

Gunshot wounds of the spine and spinal cord are divided into:

• by type of injuring projectile - into bullet and fragmentation;
• by the nature of the wound channel - through, blind, tangent;
• in relation to the spinal canal - into penetrating, non-penetrating, paravertebral;
• by level - on the cervical, thoracic, lumbar, sacral regions; isolated, combined (with damage to other organs), multiple and combined injuries are also distinguished.

Penetrating wounds of the spine are injuries in which the bony ring of the spinal canal and the dura mater are destroyed, mainly.

In the acute period of spinal cord injury, spinal shock develops, which manifests itself as inhibition of all functions of the spinal cord below the injury site. At the same time, tendon reflexes are lost, muscle tone decreases, sensitivity and function of the pelvic organs are disturbed (by the type of acute delay). The state of spinal shock lasts 2–4 weeks and is maintained by foci of spinal cord irritation: foreign bodies (metal fragments, bone fragments, fragments of ligaments), areas of traumatic and circular necrosis.

The more severe the spinal cord injury, the later its reflex activity is restored. When assessing the degree of spinal cord injury, the following clinical syndromes are distinguished:

Syndrome of complete transverse destruction of the spinal cord; characterized by tetra- and paraplegia, tetra- and paraanesthesia, dysfunction of the pelvic organs, progressive development of bedsores, hemorrhagic cystitis, rapidly advancing cachexia, edema of the lower extremities;

The syndrome of partial spinal cord injury - in the acute period is characterized by different severity of symptoms - from the preservation of movement in the limbs with a slight difference in reflexes, to paralysis with dysfunction of the pelvic organs. The upper limit of sensory disturbances is usually unstable and may change depending on circulatory disorders, cerebral edema, etc.;

Spinal cord compression syndrome in gunshot wounds - in the early period occurs most often due to pressure on the substance of the brain by a wounding projectile, bone fragments, displaced vertebrae, and also due to the formation of subdural and epidural hematomas;

Perineural radicular position syndrome is observed with a blind wound of the spine in the region of the cauda equina with a subdural location of the foreign body. The syndrome is expressed by a combination of pain and bladder disorders: in the upright position, the pain in the perineum increases, and the emptying of the bladder is more difficult than in the supine position.

Injuries to the upper cervical spine and spinal cord are characterized by a serious condition with severe respiratory failure (due to paralysis of the muscles of the neck and chest wall). Often, such injuries are accompanied by stem symptoms: loss of consciousness, swallowing disorder, and disorders of the cardiovascular system due to ascending edema.

Injuries to the lower cervical spine are accompanied by respiratory distress, high paralysis (tetraplegia), impaired sensitivity below the level of the collarbone, and often Horner's symptom (narrowing of the pupil, palpebral fissure, and some retraction of the eyeball).

If the thoracic spinal cord is damaged, paraplegia of the lower extremities develops, dysfunction of the pelvic organs and a sensitivity disorder depending on the level of the lesion (the fifth thoracic segment corresponds to the level of the nipples, the seventh to the costal arch, the tenth to the navel, the twelfth to the inguinal folds). Damage to the lumbar spinal cord, the segments of which are located at the level of I X-XI thoracic vertebrae, is accompanied by paraplegia, impaired function of the pelvic organs (like incontinence) and sensitivity disorder down from the inguinal folds.

With damage to the epiconus and roots of the initial part of the cauda equina, flaccid paralysis of the muscles of the legs, feet, buttocks occurs, and sensitivity disorders are determined on the skin of the lower extremities and in the perineum.

Wounds of the lower lumbar and sacral spine are accompanied by damage to the roots of the cauda equina and are clinically characterized by flaccid paralysis of the lower extremities, radicular pain and urinary incontinence.

Guidelines for military surgery

It is the most dangerous for human life. It is accompanied by many complications and long-term rehabilitation. Injury to the spine threatens with disability and death. The most undesirable damage to the cervical spine. Treatment should begin as early as possible with emergency care, inpatient care, and recovery.

Spinal cord injury occurs for the following reasons:

• in road traffic accidents, various injuries occur (bruises, fractures, dislocations, contusion of different parts of the spine);
• falling from height;
• extreme sports (diving, skydiving);
• domestic, industrial injuries;
• gunshot, stab wounds;
• environmental disasters (earthquakes);
• non-traumatic disease disease (cancer, arthritis, inflammation)
• severe injury.

As a result of injury, fractures, vertebral arches, dislocations and displacements, ruptures and sprains, compression, concussion of the spinal cord occur. Damage is divided into closed and open, with or without violation of the integrity of the brain.

Traumatic factors cause pain, swelling, hemorrhage and spinal deformity. Common symptoms: loss of consciousness, malfunction of organs (heart, lungs), paralysis, violation of thermoregulation of the body, the occurrence of a state of shock, weakness in the muscles, numbness of the limbs, concussion, headache, nausea.

Spinal cord contusion manifests itself as a violation of all types of sensitivity. There is a decrease, loss of sensitivity, numbness of the skin, a feeling of goosebumps. If the signs increase, surgical intervention is necessary (with compression of the brain, hematoma, bone fragments).

Spinal cord injury can cause visceral-vegetative disorders. These include dysfunction of the pelvic organs, gastrointestinal tract (increase or decrease in the formation of digestive enzymes), decreased blood circulation and lymphatic drainage in tissues.

Cervical injuries

They are the most dangerous and more often than other injuries lead to death. This is due to the fact that the centers of respiration and heartbeat are located in the medulla oblongata; in case of damage, the work of these centers stops. There are fractures of the cervical spine during sports, falls, accidents. In the case of a fracture of the upper vertebrae, death occurs in 30-40%. When the atlas is dislocated, headache, tinnitus, cramps of the upper limbs, sleep disturbance, and back pain occur.

If the cervical spine is injured at the level of C1-C4, dizziness, pain in the upper neck, aphonia, paresis, paralysis, disturbances in the work of the heart, dysphagia, and lack of sensitivity may occur. With dislocation of the C1-C4 vertebrae, radiating pains, difficulty swallowing, and a feeling of swelling of the tongue also occur.

If there is a fracture or dislocation of the two upper vertebrae, radicular syndrome manifests itself in 25% - pain in the back of the head and neck, partial impairment of brain function (manifested by severe pain in the arms, weakness in the legs). In 30%, a symptom of transverse brain damage is manifested in the form of spinal shock (reflexes are absent, sensitivity is lost, the functioning of organs is disrupted).

Spinal shock can be reversible or irreversible. Usually, after the restoration of damaged tissues, the functions return. Allocate an acute stage of shock (the first 5 days), during which the conduction of impulses stops, there is no sensitivity, reflexes. The subacute stage lasts up to 4 weeks, damaged tissues are restored, cicatricial changes are formed, blood circulation and cerebrospinal fluid movements return to normal. The interim period lasts from 3 to 6 months, there is a restoration of lost functions.

In case of trauma of the cervical spine: fractures, dislocations of the middle and lower cervical vertebrae, cerebral edema, impaired circulation of cerebrospinal fluid, hemorrhages, and hematomas may occur.

Injury to the thoracic and lumbar spine

Symptoms of damage to this department are paralysis of various muscle groups: intercostal (respiratory disorders occur), muscles of the abdominal wall, lower extremities. There is weakness in the legs, a disorder in the functioning of the pelvic organs, sensitivity decreases below the site of injury.

Diagnostics

For diagnosis and diagnosis, it is necessary to conduct a number of studies:

• Radiography is performed for all people with suspected damage, done at least in two projections;
• Computed tomography is a more accurate research method, provides information on various pathologies, reproduces cross-sectional images of the spine and brain;
• Magnetic resonance imaging will help to reveal the smallest details in case of damage (blood clots, splinters, hernia);
• Myelography allows you to accurately see all the nerve endings, which is necessary for proper diagnosis, it can detect the presence of a hematoma, hernia, tumor;
• Vertebral angiography is performed to visualize the vessels of the spine. Check the integrity of the vessels, determine the presence of hemorrhages, hematomas;
• A lumbar puncture is performed to analyze the cerebrospinal fluid. Can detect the presence of blood, infection, foreign bodies in the spinal canal.
• When making a diagnosis, the cause of the injury, the severity of clinical symptoms, the effectiveness of first aid, the results of the examination and research methods are taken into account.

Provision of emergency medical care

• it is necessary to limit mobility: place the victim on a hard surface, fix the injured area;
• prevent further damage to the body;
• if necessary, introduce painkillers;
• control breathing and pulse;
• when diagnosing shock, remove the patient from this state.

When transporting the patient, they try to avoid deformation of the spine so as not to cause further damage. In a medical institution, it is necessary to place the victim on a hard bed or a shield on which bed linen is pulled. The use of the Stricker frame is effective, it provides immobilization and patient care. Further, with the help of orthopedic treatment, deformities are eliminated, fixed, and a stable position of the spine is ensured.

Treatment

Orthopedic treatments include: reduction of fractures, dislocations, traction, long-term immobilization of the spine. In case of damage to the cervical spine, it is recommended to wear a neck brace.

Surgical treatment consists of removing foreign bodies, eliminating pressure on tissues and blood vessels, correcting deformities, restoring the anatomy of the spinal canal and brain, and stabilizing the damaged area.

If surgical treatment is necessary for spinal cord injury, the operation is performed urgently. 6-8 hours after damage, irreversible changes may occur. For surgical intervention, all contraindications are eliminated with the help of intensive therapy. They optimize disorders of the cardiovascular and respiratory systems, eliminate cerebral edema, and prevent infections.

Medical treatment involves the appointment of drugs. They use painkillers, hemostatic, anti-inflammatory drugs, stimulate an increase in immunity and body resistance. With spinal shock, atropine, dopamine, large doses of the hormone methylprednisolone are used. Hormone therapy (dexamethasone, prednisolone) reduces swelling of the nervous tissue, inflammation, and pain. With pathological muscle spasticity, centrally acting muscle relaxants (mydocalm, baclofen) are used. Broad-spectrum antibiotics are used to treat or prevent the occurrence of infectious diseases.

With spinal cord injury, hormones are contraindicated in individual sensitivity, hormone therapy increases the risk of blood clots.

Effective is the use of physiotherapy treatment. Carry out therapeutic massage, electrophoresis, electromyostimulation and biostimulation of body parts with reduced or lost sensitivity. Carry out applications with paraffin and various water procedures.

Complications

Immediately upon injury, bleeding, hematomas, ischemia, a sharp decrease in pressure, the occurrence of spinal shock, and CSF leakage occur.

After a spinal injury, there is a risk of various complications: bedsores, muscle spasticity, autonomic dysreflexia, difficulty with urination and emptying, sexual dysfunction. There may be pain in the area of ​​reduced or lost sensitivity. While caring for the sick, it is necessary to rub the skin, do exercises for the limbs, and help with bowel cleansing.

Rehabilitation

Life after a spinal cord injury can become significantly limited. To restore lost functions, it is necessary to undergo a long rehabilitation, physiotherapists will help restore the strength of the arms and legs, and teach how to perform household tasks. The patient will be taught how to use equipment for the disabled (wheelchair, toilet). Sometimes it is necessary to change the design of the house to create conditions for the patient and facilitate self-care. Modern wheelchairs make life easier for patients.

Medical rehabilitation of people with spinal cord injury involves hormone therapy, for chronic pain - painkillers, muscle relaxants, medicines to improve the functioning of the intestines, bladder, and genital organs.

Causes of emergencies in spinal lesions may be traumatic or non-traumatic.

To non-traumatic reasons include:

• Medullary processes:
  • spinal cord inflammation: myelitis, viral and autoimmune
  • medullary tumors (gliomas, ependymomas, sarcomas, lipomas, lymphomas, drip metastases); paraneoplastic myelopathy (eg, in bronchial carcinoma and Hodgkin's disease)
  • radiation myelopathy in the form of acute, from incomplete to complete, symptoms of lesions at a certain level of the spinal cord at radiation doses of 20 Gy with a latency of several weeks to months and years
  • vascular spinal syndromes: spinal ischemia (eg, after aortic surgery or aortic dissection), vasculitis, embolism (eg, decompression sickness), vascular compression (eg, due to mass effect), and spinal arteriovenous malformations, angiomas, cavernomas, or dural fistulas ( with venous stasis and congestive ischemia or hemorrhage)
  • metabolic myelopathy (with acute and subacute course); funicular myelosis with vitamin B 12 deficiency; hepatic myelopathy in liver failure
• Extramedullary processes:
  • purulent (bacterial) spondylodiscitis, tuberculous spondylitis (Pott's disease), mycotic spondylitis, epi- or subdural abscess;
  • chronic inflammatory rheumatic diseases of the spine such as rheumatoid arthritis, seronegative spondyloarthropathy (ankylosing spondylitis), psoriatic arthropathy, enteropathic arthropathy, reactive spondyloarthropathy, Reiter's disease;
  • extramedullary tumors (neurinomas, meningiomas, angiomas, sarcomas) and metastases (eg, bronchial cancer, multiple myeloma [plasmocytoma]);
  • spinal subdural and epidural hemorrhages in blood clotting disorders (anticoagulation!), condition after injury, lumbar puncture, epidural catheter and vascular malformations;
  • degenerative diseases such as osteoporotic fractures of the spine, spinal canal stenosis, herniated discs.

To traumatic reasons include:

• Contusion, infringement of the spinal cord
• Traumatic hemorrhages
• Fracture/dislocation of the vertebral body

Non-traumatic spinal cord injuries

Inflammation/infection of the spinal cord

Frequent causes of acute myelitis are primarily multiple sclerosis and viral inflammations; however, pathogens are not detected in more than 50% of cases.

Risk factors for spinal infection are:

• Immunosuppression (HIV, immunosuppressive drug therapy)
• Diabetes
• Alcohol and drug abuse
• Injuries
• Chronic diseases of the liver and kidneys.

Against the background of a systemic infection (sepsis, endocarditis), especially in these risk groups, additional spinal manifestations of infection may also be noted.

spinal ischemia

Spinal ischemia, compared with cerebral ischemia, is rare. In this regard, a favorable effect is exerted, first of all, by good collateralization of the blood flow of the spinal cord.

The following are considered as causes of spinal ischemia:

• Arteriosclerosis
• aortic aneurysm
• Operations on the aorta
• Arterial hypotension
• Obstruction/dissection of the vertebral artery
• Vasculitis
• Collagenosis
• Embolic vascular occlusion (eg, decompression sickness in divers)
• Spinal volumetric processes (intervertebral discs, tumor, abscess) with vascular compression.

In addition, there are also idiopathic spinal ischemias.

Tumors of the spinal cord

According to anatomical localization, spinal tumors/volume processes are subdivided into:

• Vertebral or extradural tumors (eg, metastases, lymphomas, multiple myeloma, schwannomas)
• Tumors of the spinal cord (spinal astrocytoma, ependymoma, intradural metastases, hydromyelia/syringomyelia, spinal arachnoid cysts).

Hemorrhage and vascular malformations

Depending on the compartments, there are:

• epidural hematoma
• subdural hematoma
• Spinal subarachnoid hemorrhage
• Hematomyelia.

Spinal hemorrhages are rare.

The reasons are:

• Diagnostic/therapeutic measures such as lumbar puncture or epidural catheter
• Oral anticoagulation
• Blood clotting disorders
• Malformations of the spinal vessels
• Injuries
• Tumors
• Vasculitis
• Manual therapy
• Rarely, aneurysms in the cervical region (vertebral artery)

Vascular malformations include:

• Dural arteriovenous fistulas
• Arteriovenous malformations
• Cavernous malformations and
• spinal angiomas.

Symptoms and signs of non-traumatic spinal cord injury

The clinical picture in spinal emergencies depends mainly on the underlying etiopathogenesis and localization of the lesion. These conditions typically present with acute or subacute neurological deficits, which include:

• Sensitization disorders (hypesthesia, par- and dysesthesia, hyperpathia) usually caudal to spinal cord injury
• Motor deficits
• Vegetative disorders.

The phenomena of prolapse may be lateralized, but they also manifest themselves in the form of acute symptoms of a transverse spinal cord lesion.

ascending myelitis can lead to damage to the brainstem with cranial nerve prolapse and dative insufficiency, which may clinically correspond to the pattern of Landry's palsy (= ascending flaccid paralysis).

Back pain, often drawing, stabbing or blunt, felt primarily in extramedullary inflammatory processes.

With local inflammation fever may initially be absent and develops only after hematogenous dissemination.

spinal tumors initially often accompanied by back pain, which is aggravated by percussion of the spine or during exercise, neurological deficits do not have to be present. Radicular pain can occur with damage to the nerve roots.

Symptoms spinal ischemia develops over a period of minutes to hours and, as a rule, covers the pool of the vessel:

• Syndrome of the anterior spinal artery: often radicular or girdle pain, flaccid tetra- or paraparesis, lack of pain and temperature sensitivity while maintaining vibration sensitivity and joint-muscular feeling
• Sulco-commissural artery syndrome
• Posterior spinal artery syndrome: loss of proprioception with ataxia when standing and walking, sometimes paresis, bladder dysfunction.

Spinal hemorrhages are characterized by acute - often unilateral or radicular - back pain, usually with incomplete symptomatology of the transverse spinal cord lesion.

Due to malformations of the spinal vessels often slowly progressing symptoms of transverse lesions of the spinal cord develop, sometimes fluctuating or paroxysmal.

At metabolic disorders it is necessary, first of all, to remember the deficiency of vitamin B12 with a picture of funicular myelosis. It often presents in patients with pernicious anemia (eg, Crohn's disease, celiac disease, malnutrition, a strict vegetarian diet) and slowly progressive motor deficits, such as spastic paraparesis and gait disturbances, and sensory deficits (paresthesias, decreased vibration sensitivity). ). Additionally, cognitive functions usually worsen (confused consciousness, psychomotor retardation, depression, psychotic behavior). Rarely, with impaired liver function (mainly in patients with a portosystemic shunt), hepatic myelopathy develops with damage to the pyramidal tract.

Polio classically proceeds in several stages and begins with a fever, followed by a meningitis stage until the development of a paralytic stage.

spinal syphilis with tabes of the spinal cord (myelitis of the posterior / lateral funiculi of the spinal cord) as a late stage of neurosyphilis, it is accompanied by progressive paralysis, sensory disturbances, stabbing or cutting pains, loss of reflexes and impaired bladder function.

Myelitis with tick-borne encephalitis often associated with "severe transverse symptomatology" involving the upper extremities, cranial nerves, and diaphragm, and has a poor prognosis.

Optic neuromyelitis(Devic's syndrome) is an autoimmune disease that predominantly affects young women. It is characterized by signs of acute (transverse) myelitis and optic neuritis.

Radiation myelopathy develops after irradiation, as a rule, with a latency of several weeks to months and may present with acute spinal symptoms (paresis, sensory disturbances). The diagnosis is indicated by the history, including the size of the radiation field.

Diagnosis of non-traumatic spinal cord injuries

Clinical examination

Localization of damage is established by the study of sensitive dermatomes, myotomes and stretch reflexes of skeletal muscles. The study of vibration sensitivity, including the spinous processes, helps in determining the level of localization.

Autonomic disorders can be identified, for example, through the tone of the anal sphincter and impaired bladder emptying with the formation of residual urine or incontinence. Limited inflammation of the spine and adjacent structures is often accompanied by pain on tapping and squeezing.

Symptoms of spinal inflammation at first can be completely non-specific, which significantly complicates and slows down the diagnosis.

Difficulties arise in the differentiation caused by the pathogen and parainfectious myelitis. In the latter case, an asymptomatic interval between a previous infection and myelitis is often described.

Visualization

If a spinal process is suspected, the method of choice is MRI in at least two projections (sagittal + 33 axial).

Spinal ischemia, inflammatory lesions, metabolic changes and tumors especially well visualized on T2-weighted images. Inflammatory or edematous changes, as well as tumors, are well displayed in STIR sequences. After the injection of a contrast agent in T1 sequences, blooming inflammatory foci and tumors are usually well differentiated (sometimes subtractions of the original T1 from T1 after the injection of a contrast agent for more accurate delimitation of the contrast). If bone involvement is suspected, T2 or STIR sequences with fat saturation, or T1 after contrast agent injection, are appropriate for better differentiation.

Spinal hemorrhages can be recognized on CT in case of emergency diagnosis. However, MRI is the method of choice for better anatomical and etiological classification. Hemorrhages on MRI are displayed differently, depending on their stage (< 24 часов, 1-3 дня и >3 days). If there are contraindications to MRI, then to assess bone damage and clarify the issue of significant mass effects in extramedullary inflammatory processes, CT of the spine with contrast is performed.

To minimize the dose of radiation received by the patient, it is advisable to determine the level of damage on the basis of the clinical picture.

In rare cases (functional imaging, intradural volume processes with bone involvement), it is advisable to perform myelography with postmyelographic computed tomography.

Degenerative changes, fractures and osteolysis of the vertebral bodies can often be recognized on a plain x-ray.

Liquor research

An important role is played by cytological, chemical, bacteriological and immunological analysis of CSF.

Bacterial inflammation usually accompanied by marked increases in cell count (> 1000 cells) and total protein. If a bacterial infection is suspected, it is necessary to strive to isolate the pathogen by sowing cerebrospinal fluid on the flora or by PCR. With signs of systemic inflammation, the bacterial pathogen is detected by blood culture.

At viral inflammations, apart from a slight or moderate increase in the number (usually from 500 to a maximum of 1000 cells), there is usually only a slight increase in the level of proteins. A viral infection may be indicated by the detection of specific antibodies (IgG and IgM) in the cerebrospinal fluid. The formation of antibodies in the CSF can be reliably confirmed by determining the avidity index of specific antibodies (AI). An index >1.5 is suspicious, and values ​​>2 indicate the formation of antibodies in the central nervous system.
Antigen detection by PCR is a fast and reliable method. This method can, in particular, provide important information in the early phase of infection, when the humoral immune response is still insufficient. In autoimmune inflammation, there is a slight pleocytosis (< 100 клеток), а также нарушения гематоэнцефалического барьера и повышение уровня белков

In multiple sclerosis, more than 80% of patients have oligoclonal bands in the CSF. Optical neuromyelitis in more than 70% of patients is associated with the presence in the serum of specific antibodies to aquaporin 4.

Other diagnostic measures

Routine laboratory diagnostics, complete blood count and C-reactive protein in the case of isolated inflammatory spinal processes do not always help, and often in the initial phase no anomalies are found in the analyzes, or there are only minor changes. However, an increase in C-reactive protein in bacterial spinal inflammation is a non-specific sign that should lead to a detailed diagnosis.

Pathogens are identified by bacterial blood culture, sometimes by biopsy (CT-guided puncture for abscess or discitis) or intraoperative sampling.

Electrophysiological studies serve to diagnose functional damage to the nervous system and, above all, to assess the prognosis.

Differential Diagnosis

Attention: such a phenomenon in the cerebrospinal fluid can occur with "cerebrospinal fluid blockade" (in the absence of cerebrospinal fluid flow as a result of mechanical displacement of the spinal canal).

The differential diagnosis for non-traumatic spinal injuries includes:

• Acute polyradiculitis (Guillain-Barré syndrome): acute "ascending" sensorimotor deficits; it is usually possible to differentiate myelitis on the basis of a typical cell-protein dissociation in the cerebrospinal fluid with an increase in total protein while maintaining a normal number of cells.
• Hyper- or hypokalemic paralysis;
• Syndromes with polyneuropathy: chronic inflammatory demyelinating polyneuropathy with acute deterioration, borreliosis, HIV infection, CMV infection;
• Myopathic syndromes (myasthenia gravis, dyskalemic paralysis, rhabdomyolysis, myositis, hypothyroidism): usually an increase in creatine kinase, and in dynamics - a typical EMG picture;
• Parasagittal cortical syndrome (eg, sickle brain tumor);
• Psychogenic symptoms of transverse lesions of the spinal cord.

Complications of emergencies in spinal lesions

• Prolonged sensorimotor deficits (paraparesis/paraplegia) with increased risk
  • deep vein thrombosis (thrombosis prevention)
  • contractures
  • spasticity
  • bedsores
• With high cervical injuries, the risk of respiratory disorders - increased risk of pneumonia, atelectasis
• Autonomic dysreflexia
• Impaired bladder function, increased risk of urinary tract infections up to urosepsis
• Impaired bowel function -» danger of excessive bloating, paralytic ileus
• Temperature regulation disorders in the case of lesions located at the level of 9-10 thoracic vertebrae with the risk of hyperthermia
• Increased risk of orthostatic hypotension

Treatment of non-traumatic spinal cord injuries

Inflammation of the spinal cord

In addition to specific therapy directed against the pathogen, general measures should first be carried out, such as the installation of a urinary catheter for violations of bladder emptying, prevention of thrombosis, changing the position of the patient, timely mobilization, physiotherapy and pain therapy.

General therapy: drug therapy depends mainly on the etiopathogenesis of the spinal lesion or on the pathogen. Often in the initial phase it is not possible to unambiguously establish the etiological affiliation or isolate pathogens, so the choice of drugs is carried out empirically, depending on the clinical course, the results of laboratory diagnostics and the study of cerebrospinal fluid, as well as on the expected spectrum of pathogens.

In the beginning, a broad combination antibiotic therapy should be carried out using an antibiotic that acts on the central nervous system.

In principle, antibiotics or virostatic agents should be used in a targeted manner.

The choice of drugs depends on the results of a study of bacteriological cultures of blood and cerebrospinal fluid or cerebrospinal fluid punctures (an angiogram is required!), As well as on the results of serological or immunological studies. In the case of a subacute or chronic course of the disease, if the clinical situation allows it, a targeted diagnosis should first be carried out, if possible with isolation of the pathogen, and, if necessary, a differential diagnosis.

In case of bacterial abscesses, in addition to antibiotic therapy (if it is possible from an anatomical and functional point of view), the possibility should be discussed and an individual decision should be made on neurosurgical debridement of the focus.

Specific therapy:

• idiopathic acute transverse myelitis. There are no placebo-controlled randomized trials that unequivocally support the use of cortisone therapy. By analogy with the treatment of other inflammatory diseases and based on clinical experience, 3-5 days of intravenous cortisone therapy with methylprednisolone at a dose of 500-1000 mg is often performed. Patients with a severe clinical condition may also benefit from more aggressive cyclophosphamide therapy and plasmapheresis.
• myelitis associated with herpes simplex and herpes zoster: acyclovir.
• CMV infections: ganciclovir. In rare cases of intolerance to acyclovir in HSV, varicella-zoster or CMV infections, foscarnet can also be used.
• neuroborreliosis: 2-3 weeks antibiosis with ceftriaxone (1x2 g/day IV) or cefotaxime (3x2 g/day IV).
• neurosyphilis: penicillin G or ceftriaxone 2-4 g/day intravenously (the duration of therapy depends on the stage of the disease).
• tuberculosis: multi-month four-component combination therapy with rifampicin, isoniazid, ethambutol and pyrazinamide.
• spinal abscesses with progressive neurological prolapse (eg, myelopathic signal on MRI) or pronounced signs of a volumetric process require urgent surgical intervention.
• spondylitis and spondylodiscitis are often treated conservatively with immobilization and (if possible targeted) antibiotic therapy for at least 2-4 weeks. Antibiotics that act well on the CNS for Gram-positive pathogens include, for example, fosfomycin, ceftriaxone, cefotaxime, meropenem and linezolid. In the case of tuberculous osteomyelitis, multi-month anti-tuberculosis combination therapy is indicated. In the absence of effect or severe symptoms, before
  In general, bone destruction with signs of instability and/or depression of the spinal cord may require surgical debridement with removal of the intervertebral disc and subsequent stabilization. Surgical measures should be discussed primarily in the case of compression of neural structures.
• - neurosarcoidosis, neuro-Behcet, lupus erythematosus: immunosuppressive therapy; depending on the severity of the disease, cortisone is used and, mainly in long-term therapy, also methotrexate, azathioprine, cyclosporine and cyclophosphamide.

spinal ischemia

Therapeutic options for spinal ischemia are limited. There are no evidence-based medicine recommendations. The restoration or improvement of the spinal circulation comes to the fore in order to prevent further damage. Accordingly, it is necessary, as far as possible, to therapeutically address the underlying causes of spinal ischemia.

In case of vascular occlusion, blood coagulation (anticoagulation, heparinization) should be taken into account. Administration of cortisone is not recommended due to potential side effects.

In the initial phase, the basis of therapy is the control and stabilization of vital functions, as well as the prevention of complications (infections, bedsores, contractures, etc.). In the future, neurorehabilitation measures are shown.

Tumors

In the case of isolated volumetric processes with compression of the spinal cord, urgent surgical decompression is necessary. The longer there is or continues spinal cord injury (>24 hours), the worse the chances of recovery. In the case of radiosensitive tumors or metastases, the possibility of irradiation is considered.

Other therapeutic options, depending on the type of tumor, its prevalence and clinical symptoms, include conservative therapy, radiation (including gamma knife), chemotherapy, thermocoagulation, embolization, vertebroplasty, and with signs of instability, various stabilization measures. Therapeutic approaches should be discussed interdisciplinary, with neurologists, neurosurgeons/trauma surgeons/orthopedics oncologists (radiotherapy specialists).

For spinal volume processes with edema, cortisone is used (eg 100 mg hydrocortisone per day, according to the standards of the German Society of Neurology 2008, alternatively dexamethasone, eg 3 x 4-8 mg/day). The duration of treatment depends on the clinical course and/or changes in imaging data.

Spinal hemorrhages

Depending on the clinical course and volumetric nature of the process, sub- or epidural spinal hemorrhage may require surgical intervention (often decompressive laminectomy with blood aspiration).

With small hemorrhages without signs of a mass effect and with minor symptoms, conservative expectant management with control of the dynamics of the process is initially justified.

Spinal vascular malformations respond well to endovascular therapy (embolization). First of all, type I arteriovenous malformations (=fistulas) can often be occluded. Other arteriovenous malformations may not always be occluded, but can often be reduced in size.

Prognosis for non-traumatic spinal cord injuries

Prognostically unfavorable factors in inflammatory lesions of the spinal cord include:

• Initially rapidly progressive course
• Duration of neurological loss for more than three months
• Detection of protein 14-3-3 in CSF as a sign of neuronal damage
• Pathological motor and sensory evoked potentials, as well as signs of denervation on EMG.

Approximately 30-50% of patients with acute transverse myelitis have a poor outcome with residual severe disability, and the prognosis for multiple sclerosis is better than for patients with other causes of transverse spinal cord syndrome.

The prognosis of spondylitis/spondylodiscitis and spinal abscesses depends on the size and duration of damage to neural structures. The decisive factor is therefore timely diagnosis and therapy.

The prognosis of spinal ischemia, due to limited therapeutic options, is poor. Most patients have a persistent neurological deficit, depending mainly on the type of primary lesion.

The prognosis for spinal volumetric processes depends on the type of tumor, its prevalence, the scale and duration of damage to neural structures, and the possibilities or effect of therapy.

The prognosis of spinal hemorrhages is determined mainly by the severity and duration of neurological deficits. With small hemorrhages and conservative tactics, the prognosis in most cases can be favorable.

Traumatic spinal cord injury

Spinal injuries occur as a result of high-energy force impact. Common reasons include:

• high speed crash
• Fall from a great height and
• Direct force.

Depending on the accident mechanism, axial forces can lead to compression fractures of one or more vertebrae, as well as to flexion-extension injuries of the spine with distraction and rotational components.

Approximately 15-20% of patients with severe traumatic brain injury have concomitant injuries of the cervical spine. Approximately 15-30% of patients with polytrauma have spinal injuries. Fundamentally recognized is the allocation in the spine of the anterior, middle and posterior columns or column ( three-column model Denis), and the anterior and middle columns of the spine include the vertebral bodies, and the posterior - their dorsal segments.

A detailed description of the type of injury reflecting functional and prognostic criteria is classification of injuries of the thoracic and lumbar spine, according to which spinal injuries are divided into three main types A, B and C, where each of the categories includes three further subtypes and three subgroups. Instability increases in the direction from type A to type C and within the respective subgroups (from 1st to 3rd).

For injuries of the upper cervical spine, due to anatomical and biomechanical features, there is separate classification.

In addition to fractures, the following injuries occur with spinal injuries:

• Hemorrhages in the spinal cord
• Bruises and swelling of the spinal cord
• Spinal cord ischemia (due to compression or rupture of arteries)
• Ruptures, as well as displacement of the intervertebral discs.

Symptoms and signs of traumatic spinal cord injury

In addition to the anamnesis (primarily the mechanism of the accident), the clinical picture plays a decisive role for further diagnostic and therapeutic measures. The following are the main clinical aspects of traumatic spinal injuries:

• Pain in the area of ​​the fracture during tapping, compression, movement
• Stable fractures are usually painless; unstable fractures often cause more severe pain with limited movement
• Hematoma at the fracture site
• Spinal deformity (such as hyperkyphosis)
• Neurological prolapse: radicular pain and / or sensory disturbances, symptoms of incomplete or complete transverse spinal cord injury, dysfunction of the bladder and rectum in men, sometimes priapism.
• Respiratory failure with high cervical paralysis (C 3-5 innervate the diaphragm).
• Prolapse of the brainstem/cranial nerves in atlanto-occipital dislocations.
• Rarely traumatic injuries of the vertebral or basilar arteries.
• Spinal shock: transient loss of function at the level of spinal cord injury with loss of reflexes, loss of sensorimotor functions.
• Neurogenic shock: develops mainly with injuries of the cervical and thoracic spine in the form of a triad: hypotension, bradycardia and hypothermia.
• Autonomic dysreflexia in case of lesions within T6; as a result of the action of various nociceptive stimuli (for example, tactile irritation), an excessive sympathetic reaction with vasoconstriction and a rise in systolic pressure up to 300 mm Hg, as well as a decrease in peripheral circulation (pallor of the skin) may develop below the level of the focus. Above the level of the focus in the spinal cord, compensatory vasodilation develops (skin redness and sweating). In view of blood pressure crises and vasoconstriction - with the risk of cerebral hemorrhage, cerebral and myocardial infarction, arrhythmias up to cardiac arrest - autonomic dysreflexia is a serious complication.
• Brown-Séquard Syndrome: Usually a semi-spinal cord lesion with ipsilateral paralysis and loss of proprioception, as well as contralateral loss of pain and temperature sensations.
• Medullary cone syndrome: damage to the sacral spinal cord and nerve roots of the lumbar region with areflexia of the bladder, intestines and lower extremities with sometimes persistent reflexes at the sacral level (for example, bulbocavernosus reflex).
• Cauda equina syndrome: damage to the lumbosacral nerve roots with areflexia of the bladder, intestines and lower extremities.

Diagnosis of traumatic spinal cord injuries

The classification developed by the American Spinal Injury Association can be used to determine the level and severity of spinal cord injury.

Every patient with neurological deficits due to trauma needs adequate and timely primary diagnostic imaging. In patients with moderate to severe traumatic brain injury, it is necessary to examine the cervical spine, including the upper part of the thoracic region.

For mild to moderate injuries (without neurological deficits), the following signs indicate the need for timely imaging:

• Changing state of consciousness
• Intoxication
• Pain in the spine
• Distraction injury.

An important role in the decision to perform imaging is played by the patient's advanced age and significant past or concomitant diseases, as well as the mechanism of the accident.

Patients with a minor mechanism of injury and a low risk of damage often do not need hardware diagnostics, or only plain radiography (if indicated, additional functional radiography) is sufficient. As soon as the likelihood of spinal injury is identified based on risk factors and the course of injury, due to higher sensitivity, CT of the spine should be performed initially.

In case of possible vascular damage, CT angiography is additionally required.

MRI is inferior to CT in the emergency diagnosis of spinal injury, since it allows only a limited assessment of the extent of bone damage. However, in case of neurological deficits and ambiguous CT results, MRI should be additionally performed in case of emergency diagnosis.

MRI is shown mainly in the sub-acute phase and to monitor the dynamics of neural damage. In addition, the ligamentous and muscular components of the injury can be better assessed, as well as, if necessary, lesions in these components.

Visualization should answer the following questions:

• Is there any trauma at all?
• If yes, what type (fracture, dislocation, hemorrhage, brain compression, ligament lesions)?
• Is there an unstable situation?
• Is surgery required?
• Daffner recommends assessing spinal injury as follows:
• Alignment and anatomical abnormalities: anterior and posterior margin of the vertebral bodies in the sagittal plane, spinolaminar line, lateral masses, inter-articular and interspinous distance;
• Bone - violation of the integrity of the bone: rupture of the bone / fracture line, compression of the vertebral bodies, "bone nodules", displaced bone fragments;
• Cartilage-anomalies of the cartilage / joint cavity: an increase in the distances between the small vertebral joints (> 2 mm), inter-articular and interspinous distances, expansion of the intervertebral space;
• Soft tissue - soft tissue abnormalities: hemorrhages with extension to the retrotracheal (< 22 мм) и ретрофарингеальное пространство (>7 mm), paravertebral hematomas.

In case of severe injuries of the spine, a search for other injuries (skull, chest, abdomen, blood vessels, limbs) should always be carried out.

Laboratory diagnostics includes a hemogram, coagulogram, determination of the level of electrolytes and functional indicators of the kidneys.

For neurological disorders in subacute phase needs to be additional electrophysiological diagnostics to assess the extent of functional damage.

Complications of injuries of the spine and spinal cord

• Spinal instability with secondary spinal cord injuries
• Spinal cord injury (myelopathy) due to compression, contusion with various types of prolapse:
• - complete transverse paralysis (depending on the level of tetra- or paraplegia and corresponding sensory deficits)
• incomplete transverse paralysis (paraparesis, tetraparesis, sensory deficits)
• With a high cervical transverse lesion - respiratory failure
• Cardiovascular Complications:
• orthostatic hypotension (most pronounced in the initial phase, improvement over time)
• loss/weakening of diurnal fluctuations in blood pressure
• cardiac arrhythmias (in the case of lesions above T6, mainly bradycardia as a result of loss of sympathetic innervation and dominance of vagus nerve stimulation)
• Deep vein thrombosis and pulmonary embolism
• Long-term complications of transverse paralysis:
• areflexia (diagnosis = combination of arterial hypertension and vasoconstriction below the level of injury)
• post-traumatic syringomyelia: symptoms are often months or years later with neurological pain above the level of the focus, as well as an increase in neurological deficits and spasticity, deterioration in the functions of the bladder and rectum (diagnosis is established using MRI)
• heterotopic ossification = neurogenic paraarticular ossification below the level of the lesion
• spasticity
• painful contractures
• bedsores
• chronic pain
• urinary disorders with an increased percentage of urinary tract/kidney infections
• increased risk of infections (pneumonia, sepsis)
• intestinal motility and bowel movements
• psychological and psychiatric problems: stress disorder, depression

Treatment of traumatic spinal cord injuries

Depending on the scale of neurological damage and the immobility associated with them, great importance is attached to conservative, preventive and rehabilitation measures:

• Intensive medical monitoring, especially in the initial phase, to maintain normal cardiovascular and pulmonary functions;
• With arterial hypotension, an attempt at therapy by adequate fluid replacement; in the initial phase, according to indications, the appointment of vasopressors;
• Prevention of bedsores, thrombosis and pneumonia;
• Depending on the stability and course of the disease, early mobilization and physiotherapy measures.

Attention: autonomic disorders (orthostatic hypotension, autonomic dysreflexia) significantly complicate mobilization.

The indication for surgical intervention (decompression, stabilization) depends primarily on the type of injury. In addition to eliminating possible myelocompression, surgical intervention is necessary in unstable situations (injuries of types B and C).

Surgery requires the appropriate competence of neurosurgeons, trauma surgeons and orthopedists.

In severe traumatic compression of the spinal cord with neurological symptoms, urgent surgical decompression is indicated (within the first 8-12 hours). In the absence of neurological prolapse or in case of inoperability, depending on the type of injury, the possibility of conservative (non-invasive) treatment tactics is considered individually, for example, using a head HALO fixator for injuries of the cervical spine.

The use of methylprednisolone in spinal cord injury remains controversial. Despite scientific indications of an effect in case of early onset, critics note primarily side effects (eg, increased incidence of pneumonia and sepsis) and possible comorbid injuries (eg, traumatic brain injury, CRASH study). In case of spinal cord edema (or expected edema), methylprednisolone (eg Urbason) may be given. As a bolus, 30 mg/kg of body weight is administered intravenously followed by a long-term infusion. If the introduction is carried out within the first three hours after injury, a long-term infusion is carried out within 24 hours, if started between 3 and 8 hours after injury - within 48 hours.

The therapy of autonomic dysreflexia consists, first of all, in the elimination of the provoking stimulus. For example, a clogged urinary catheter that caused a distension of the bladder, inflammation of the skin, distension of the rectum. With persistent, despite the elimination of provoking stimuli, arterial hypertension, medications are used to reduce pressure, such as nifedipine, nitrates or captopril.

Prognosis for traumatic spinal cord injuries

The prognosis depends mainly on the location of the injury, its severity and type (polysegmental or monosegmental), as well as on the primary neurological status. In addition to the clinical picture, MRI is necessary to elucidate morphological lesions, and additional electrophysiological diagnostics (evoked sensory and motor potentials, EMG) are required to identify functional foci. Depending on the primary damage, complete loss of function, partial loss of motor and sensory functions, but also their full recovery are possible. The prognosis for severe intramedullary hemorrhage, edema, and spinal cord compression is poor.

At cervical spinal cord injury the syndrome of complete conduction impairment first manifests itself as flaccid tetraplegia with loss of tendon and periosteal reflexes on the arms and legs, loss of abdominal and cremaster reflexes, the absence of all types of sensitivity downward from the level of spinal cord injury and dysfunction of the pelvic organs in the form of persistent retention of urine and feces.

With the syndrome of partial conduction disturbance of the cervical spinal cord, neurological disorders are less severe, there is a dissociation between the degree of movement loss, sensitivity and dysfunction of the pelvic organs, as well as reflex disorders.

Cervical spinal cord injury are accompanied by paralysis of the striated muscles of the chest, which leads to severe respiratory disorders, often requiring the imposition of a tracheostomy and the use of artificial lung ventilation. Damage at the level of the IV cervical segment, along with this, leads to paralysis of the diaphragm and, if the patient is not urgently transferred to machine breathing, to his death.

The severity of the condition of the victim with damage to the cervical spinal cord often exacerbates the ascending edema of the medulla oblongata and the appearance of bulbar symptoms - swallowing disorders, bradycardia followed by tachycardia, nystagmus and, if the therapy is ineffective, respiratory arrest due to paralysis of the respiratory center. The occurrence of bulbar symptoms immediately after injury indicates a combined injury to the cervical spinal cord and brain stem sections at the same time, which is an unfavorable sign.

In the absence of an anatomical interruption of the spinal cord, its conductive functions are gradually restored, active movements appear in paralyzed limbs, sensitivity improves, and the function of the pelvic organs normalizes.

At chest injury of the spinal cord, flaccid paralysis occurs (with less gross damage - paresis) of the muscles of the legs with loss of abdominal reflexes, as well as tendon reflexes on the lower extremities. Sensitivity disorders are usually conductive in nature (corresponding to the level of damage to the spinal cord), disorders of the functions of the pelvic organs consist in urinary and fecal retention.

At upper thoracic injury of the spinal cord, paralysis and paresis of the respiratory muscles occur, which leads to a sharp weakening of breathing. Damage at the level III-V of the thoracic segments of the spinal cord is often accompanied by a violation of cardiac activity.

At lumbar spine injury of the spinal cord, flaccid paralysis of the muscles of the legs along their entire length or the muscles of the distal sections is observed, and all types of sensitivity below the injury site are also disturbed. At the same time, cremasteric, plantar, Achilles reflexes fall out, and with higher lesions, knee reflexes. At the same time, abdominal reflexes are preserved. Urinary and fecal retention is often replaced by a paralytic condition of the bladder and rectum, resulting in the development of fecal and urinary incontinence.

In the absence of an anatomical interruption of the spinal cord, as well as in the syndrome of a partial violation of its conduction, a gradual restoration of impaired functions is noted.

Clinically progressive traumatic disease can manifest itself:

- myelopathy syndromes (syringomyelic syndrome, amyotrophic lateral sclerosis syndrome, spastic paraplegia, spinal circulation disorders);

- spinal arachnoiditis, characterized by polyradicular pain syndrome, aggravation of existing conduction disorders;

- dystrophic process in the form of osteochondrosis, deforming spondylosis with persistent pain syndrome.

Complications and consequences of injuries of the spine and spinal cord are divided as follows:

- infectious and inflammatory complications;

- neurotrophic and vascular disorders;

- dysfunction of the pelvic organs;

- orthopedic consequences.

Infectious and inflammatory complications can be early (developing in the acute and early periods of PSMT) and late. In the acute and early period, purulent-inflammatory complications are primarily associated with infection of the respiratory and urinary systems, as well as with a decubitus process, which proceeds as a purulent wound. With open PSCI, it is also possible to develop such terrible complications as purulent epiduritis, purulent meningomyelitis, spinal cord abscess, osteomyelitis of the bones of the spine. Late infectious and inflammatory complications include chronic epiduritis and arachnoiditis.

bedsores- one of the main complications that occur in patients with spinal injuries, which are accompanied by spinal cord injuries. According to various sources, they occur in 40-90% of patients with injuries of the spine and spinal cord. Quite often, the course of deep and extensive bedsores in the necrotic-inflammatory stage is accompanied by severe intoxication, a septic state, and in 20% of cases ends in death. In many works concerning spinal patients, bedsores are defined as trophic disorders. Without a violation of tissue trophism, bedsores cannot occur, and their development is due to spinal cord injury. With this interpretation, the appearance of bedsores in spinal patients becomes inevitable. Nevertheless, in a number of spinal patients, bedsores are not formed. Some authors associate the formation of bedsores with factors of compression, shearing force and friction, the prolonged effect of which on the tissues between the bones of the skeleton and the surface of the bed causes ischemia and the development of necrosis. Violation of blood circulation (ischemia) with prolonged compression of soft tissues ultimately leads to local trophic disorders and necrosis of varying degrees, depending on the depth of tissue damage. Soft tissue ischemia, which turns into necrosis during prolonged exposure, in combination with infection and other adverse factors, leads to a violation of the patient's immunity, causes the development of a severe septic condition, accompanied by intoxication, anemia, and hypoproteinemia. A prolonged purulent process often leads to amyloidosis of the internal organs, which results in the development of renal and liver failure.

Decubitus in the sacrum they occupy the first place in frequency (up to 70% of cases) and usually appear in the initial period of traumatic disease of the spinal cord, which prevents early rehabilitation measures and in some cases does not allow timely reconstructive interventions on the spine and spinal cord.

When assessing the condition of bedsores, you can use the classification proposed by A.V. Garkavi, in which six stages are distinguished: 1) primary reaction; 2) necrotic; 3) necrotic-inflammatory; 4) inflammatory-regenerative; 5) regenerative scar; 6) trophic ulcers. Clinically, bedsores in the primary reaction stage (reversible stage) were characterized by limited skin erythema, blistering in the sacrum.

Neurotrophic and vascular disorders arise in connection with the denervation of tissues and organs. In the soft tissues of patients with PSCI, bedsores and poorly healing trophic ulcers develop very quickly. Bedsores and ulcers become the entrance gates of infection and sources of septic complications, leading to death in 20-25% of cases. For the anatomical break of the spinal cord, the occurrence of so-called solid edema of the lower extremities is characteristic. Metabolic disorders (hypoproteinemia, hypercalcemia, hyperglycemia), osteoporosis, anemia are characteristic. Violation of the autonomic innervation of the internal organs leads to the development of purulent-necrotic ulcerative colitis, enterocolitis, gastritis, acute gastrointestinal bleeding, dysfunction of the liver, kidneys, pancreas. There is a tendency to stone formation in the biliary and urinary tract. Violation of the sympathetic innervation of the myocardium (with injuries of the cervical and thoracic spinal cord) is manifested by bradycardia, arrhythmia, orthostatic hypotension. Coronary heart disease may develop or worsen, while patients may not feel pain as a result of impaired noceptive afferent impulses from the heart. On the part of the pulmonary system, more than 60% of patients develop pneumonia in the early period, which is one of the most common causes of death of victims.

One of the complications is also autonomic dysreflexia. Autonomic dysreflexia is a powerful sympathetic reaction that occurs in response to pain or other stimuli in patients with a level of spinal cord injury above Th6. In patients with tetraplegia, this syndrome is observed, according to various authors, in 48-83% of cases, usually two or more months after the injury. The cause is pain or proprioceptive impulses due to bladder distension, catheterization, gynecological or rectal examination, as well as other intense influences. Normally, proprioceptive and pain impulses travel to the cerebral cortex along the posterior columns of the spinal cord and the spinothalamic tract. It is believed that when these pathways are interrupted, the impulse circulates at the spinal level, causing excitation of sympathetic neurons and a powerful "explosion" of sympathetic activity; at the same time, descending supraspinal inhibitory signals, which normally modulate the autonomic response, do not have the proper inhibitory effect due to damage to the spinal cord. As a result, a spasm of peripheral vessels and vessels of internal organs develops, which leads to a sharp rise in blood pressure. Uncorrected hypertension can lead to loss of consciousness, to the development of intracerebral hemorrhage, and acute heart failure.

Another formidable complication, often leading to death, is deep vein thrombosis, which occurs according to various sources in 47-100% of patients with PSCI. The risk of deep vein thrombosis is highest in the first two weeks after injury. The consequence of deep vein thrombosis can be pulmonary embolism, which occurs on average in 5% of patients and is the leading cause of death in PSCI. At the same time, as a result of damage to the spinal cord, typical clinical symptoms of embolism (chest pain, dyspnea, hemoptysis) may not be present; The first signs may be cardiac arrhythmias .

Pelvic organ dysfunction appear urination disorders and defecation . In the stage of spinal shock, there is an acute urinary retention associated with a deep depression of the reflex activity of the spinal cord. As the shock emerges, the form of neurogenic bladder dysfunction depends on the level of spinal cord injury. With the defeat of the suprasegmental sections (the bladder receives parasympathetic and somatic innervation from the S2-S4 segments), a violation of urination develops according to the conduction type. Initially, there is urinary retention associated with an increase in the tone of the external sphincter of the bladder. Paradoxical ischuria can be observed: with a full bladder, urine is excreted drop by drop as a result of passive stretching of the bladder neck and bladder sphincters. With the development of automatism of the parts of the spinal cord located distal to the level of the lesion (two to three weeks after the injury, and sometimes in longer periods), a “reflex” (sometimes called “hyperreflex”) bladder is formed: the spinal center of urination begins to work , localized in the cone of the spinal cord, and urination occurs reflexively, according to the type of automatism, in response to the filling of the bladder and irritation of the receptors of its walls, while there is no arbitrary (cortical) regulation of urination. There is urinary incontinence. Urine is released suddenly, in small portions. There may be a paradoxical interruption of urination due to involuntary transient inhibition of the urinary flow during reflex emptying. At the same time, an imperative urge to empty the bladder indicates an incomplete violation of the conduction of the spinal cord (preservation of the afferent pathways from the bladder to the cerebral cortex), while spontaneous sudden emptying of the bladder without an urge indicates a complete violation of the conduction of the spinal cord. The feeling of the process of urination itself and the feeling of relief after urination (preservation of the pathways of temperature, pain and proprioceptive sensitivity from the urethra to the cerebral cortex) also indicate an incomplete lesion of the conduction tracts. With a suprasegmental lesion, the "cold water" test is positive: a few seconds after the introduction of 60 ml of cold water through the urethra into the bladder, water, and sometimes the catheter, is pushed out with force. The tone of the external rectal sphincter is also increased. Over time, dystrophic and cicatricial changes may occur in the walls of the bladder, leading to the death of the detrusor and the formation of a secondarily contracted bladder (“organic areflex bladder”). In this case, the absence of a cystic reflex is observed, true urinary incontinence develops.

With a spinal cord injury with direct damage to the spinal centers of urination (sacral segments S2-S4), loss of bladder emptying reflex in response to its completion. A hyporeflex form of the bladder develops (“functional areflex bladder”), characterized by low intravesical pressure, a decrease in detrusor strength, and a sharply inhibited urination reflex. The preservation of the elasticity of the bladder neck leads to overdistension of the bladder and a large amount of residual urine. Strained urination is characteristic (to empty the bladder, the patient strains or makes manual extrusion). If the patient stops straining, emptying stops (passive intermittent urination). The "cold water" test is negative (a reflex response in the form of expulsion of water introduced into the bladder is not observed within 60 seconds). The anal sphincter is relaxed. Sometimes the bladder is emptied automatically, but not due to the spinal reflex arc, but due to the preservation of the function of the intramural ganglia. It should be noted that the sensation of bladder distention (appearance of equivalents) sometimes persists with incomplete spinal cord injury, often in the lower thoracic and lumbar region due to preserved sympathetic innervation (the sympathetic innervation of the bladder is associated with segments Th1, Th12, LI, L2). As dystrophic processes develop in the bladder and the neck of the bladder loses elasticity, an organic areflex bladder and true incontinence are formed with a constant release of urine as it enters the bladder.

When identifying clinical syndromes, the main importance is attached to the tone of the detrusor and sphincter and their relationship. Detrusor tone or the force of its contraction is measured by the increase in intravesical pressure in response to the introduction of an always constant amount of liquid - 50 ml. If this increase is 103 + 13 mm aq. Art., the tone of the detrusor of the bladder is considered normal, with a smaller increase - reduced, with a larger one - increased. Normal indicators of sphincterometry are 70-11 mm Hg. Art.

Depending on the ratio of the state of the detrusor and the sphincter, several syndromes are distinguished.

Atonic syndrome it is noted more often with damage to the cone of the spinal cord, that is, the spinal centers for the regulation of urination. In a cystometric study, the introduction of 100-450 ml of fluid into the bladder does not change the zero bladder pressure. The introduction of large volumes (up to 750 ml) is accompanied by a slow increase in intravesical pressure, but it does not exceed 80-90 mm aq. Art. Sphincterometry in atonic syndrome reveals low levels of sphincter tone - 25-30 mm Hg. Art. Clinically, this is combined with atony and areflexia of skeletal muscles.

Detrusor hypotension syndrome- also the result of segmental dysfunctions of the bladder, while due to a decrease in the tone of the detrusor, the capacity of the bladder increases to 500-700 ml. Sphincter tone can be low, normal, or even high.

Syndrome of predominant sphincter hypotension observed with injuries at the level of S2-S4 segments; it is characterized by frequent involuntary separation of urine without urge. With sphincterometry, a distinct decrease in the tone of the sphincter is revealed, and on the cystogram - a slightly reduced or normal tone of the detrusor. Palpation examination of the sphincter of the rectum and perineal muscles is determined by low tone.

Detrusor and Sphincter Hypertension Syndrome noted in patients with a conductive type of bladder dysfunction. Cystometrically, with the introduction of 50-80 ml of liquid into the bladder, a sharp jump in intravesical pressure up to 500 mm aq. Art. With sphincterometry, its tone is high - from 100 to 150 mm Hg. Art. There are sharp contractions of the muscles of the perineum in response to their palpation.

The syndrome of predominant detrusor hypertension during cystometry is characterized by an increase in detrusor tone with a small bladder capacity (50-150 ml), there is a high jump in intravesical pressure in response to the introduction of 50 ml of fluid, and the sphincter tone can be normal, increased or decreased.

To determine the electrical excitability of the bladder, transrectal electrical stimulation is also used. With gross dystrophic processes in the bladder, the detrusor loses its excitability, which is manifested by the absence of an increase in intravesical pressure in response to electrical stimulation. The degree of dystrophic processes is determined by the number of collagen fibers by the method of bladder biopsy (in case of infection of the urinary tract or significant trophic disorders in the wall of the bladder, a biopsy is not indicated).

Often, spinal injury is combined with impaired urinary function and the development of urinary tract infections(MVP). Currently, urinary tract infections (UTIs) are the main cause of morbidity and mortality in patients with spinal cord injury. About 40% of infections in this category of patients are of nosocomial origin and most of them are associated with bladder catheterization. UTIs are the cause of bacteremia in 2-4% of cases, while the probability of death in patients with urosepsis using modern tactics for managing this category of patients is from 10 to 15%, and this figure is three times higher than in patients without bacteremia.

MVP infection depends not only on risk factors due to both denervation of the bladder and the chosen method of catheterization. The overall incidence of UTI in spinal patients is 0.68 per 100 people. The methods of permanent drainage and the use of open systems are recognized as the most dangerous from the point of view of infection. The probability of developing an infection in this case is 2.72 cases per 100 patients, while when using intermittent catheterization and closed catheterization systems, this figure is 0.41 and 0.36 cases per 100 people per day, respectively. Spinal patients are characterized by an atypical and low-symptomatic course of UTI.

Violation of the act of defecation in SSCI also depends on the level of spinal cord injury. With an over segmental lesion, the patient ceases to feel the urge to defecate and fill the rectum, the external and internal sphincters of the rectum are in a state of spasm, and persistent stool retention occurs. With the defeat of the spinal centers, a flaccid paralysis of the sphincters and a violation of the reflex intestinal motility develop, which is manifested by true fecal incontinence with its passage in small portions when it enters the rectum. In a more distant period, automatic emptying of the rectum may occur due to the functioning of the intramural plexus. With PSMT, the occurrence of hypotonic constipation associated with hypomobility of the patient, weakness of the abdominal muscles, and intestinal paresis is also possible. Hemorrhoidal bleeding is often observed.

Orthopedic consequences PSCI can be conditionally divided according to their localization into vertebral, that is, associated with a change in the shape and structure of the spine itself, and extravertebral, that is, due to a change in the shape and structure of other elements of the musculoskeletal system (pathological positions of limb segments, joint contractures, etc.) . According to the nature of the functional disorders that occur with PSCI, orthopedic consequences can also be divided into static, that is, accompanied by a violation of body statics, and dynamic, that is, associated with a violation of dynamic functions (locomotion, manual manipulation, etc.). Orthopedic consequences may be as follows: instability of the injured spine; scoliosis and kyphosis of the spine (kyphotic deformities with a kyphosis angle exceeding 18-20° are especially often progressing); secondary dislocations, subluxations and pathological fractures; degenerative changes in the intervertebral discs, joints and ligaments of the spine; deformation and narrowing of the spinal canal with compression of the spinal cord. These consequences are usually accompanied by a persistent pain syndrome, limited mobility of the injured spine and its functional failure, and in cases of spinal cord compression - a progressive dysfunction of the spinal cord. Orthopedic disorders that have arisen in the absence of timely treatment often progress and lead the patient to disability.

A large group of orthopedic consequences are secondary deformities of the limbs, joints, false joints and contractures, which are formed in the absence of orthopedic prophylaxis within a few weeks after the primary injury.

A fairly common complication of PSCI is heterotopic ossification, which usually develops in the first six months after injury, according to various sources, in 16-53% of patients. Ectopic ossificates appear only in areas below the neurological level of the lesion. Areas of large joints of the extremities (hip, knee, elbow, shoulder) are usually affected.

Considering the concept of G. Selye (1974) about "stress" and "distress" in clinical, psychological and social aspects, it can be assumed that in the clinic of complicated injuries of the spine and spinal cord, in addition to biological, there are also general non-specific and private specific personal, psychological and social adaptive reactions, currently studied only in general terms, which significantly affects the degree of rehabilitation of patients.

An analysis of the identified neuropsychiatric disorders showed that among the factors that determine the state of the neuropsychic sphere, the leading role is played by traumatic, associated with damage to the cervical spinal cord, which is largely involved in the regulation of mental functions of the highest level.

It should be noted that injuries of the cervical spinal cord do not exclude the presence of a combined craniocerebral injury and the development of a shock state, which also contributes to mental disorders in the long term. This manifests itself in the form of a violation of spatial orientation, body schema, visual, auditory and speech disorders, decreased attention and memory, and general exhaustion of mental processes.

Another factor determining the degree of mental disorders is the severity of the consequences of cervical spinal cord injury in the form of pronounced motor and sensory disorders, dysfunction of the pelvic organs, disorders of the respiratory and cardiovascular systems and metabolism.

The third significant factor in the formation of mental disorders in patients in the late period of traumatic spinal cord disease is social. Movement restrictions, the dependence of a patient with a cervical spine injury on outside care in everyday life, social maladjustment - all this determines a depressed state of mind, exacerbates functional and somatic disorders. It should be emphasized that the social factor, being complex, includes both purely social and personal components. The social components include such as the establishment of disability, the inability to perform work, a decrease in the level of material support, isolation, narrowing the circle of communication and restriction of types of occupation. To personal - relationships in the family, difficulties in sexual life, problems of giving birth and raising children, dependence on outside care, etc.

As a result of studying all the data on the condition of a patient with TBCI, it is necessary to formulate a complete functional diagnosis, which should include the following sections:

1. Diagnosis according to ICD 10 (T 91.3) - consequences of spinal cord injury or post-traumatic myelopathy.

2. The nature of the injury (traumatic dislocation, fracture-dislocation, fracture, injury, etc.), level of injury, date of injury. For example: complicated compression fracture-dislocation C6-T2. Type of spinal cord injury according to the ASIA scale.

3. The level of complete and incomplete damage to the spinal cord (sensory, motor on both sides of the patient's body).

4. Existing syndromes of spinal cord injury.

5. Existing complications.

6. Concomitant diseases.

7. The degree of limitation of functional activity and vital activity.

Ivanova G.E., Tsykunov M.B., Dutikova E.M. Clinical picture of traumatic disease of the spinal cord // Rehabilitation of patients with traumatic disease of the spinal cord; Under total ed. G.E. Ivanova, V.V. Krylova, M.B. Tsykunova, B.A. Polyaev. - M.: JSC "Moscow Textbooks and Cartolithography", 2010. - 640 p. pp. 74-86.

• Back
• Forward

Ratings (0)

The rapid rhythm of life makes us rush somewhere, rush, run without looking back. But it is worth an unsuccessful fall - and a sharp pain pierces the back. A disappointing diagnosis from the lips of a doctor interrupts the endless rush. Spinal cord injury - frightening words, but are they a sentence?

What is spinal cord injury

The spinal cord of a person is reliably protected. It is closed by a strong bone frame of the spine, while it is abundantly supplied with nutrients through the vascular network. Under the influence of various factors - external or internal - the activity of this stable system can be disrupted. All changes that develop after damage to the cerebrospinal substance, surrounding membranes, nerves and blood vessels are collectively known as "spinal cord injury".

A spinal cord injury may be called a spinal cord injury or, in a latinized manner, a spinal cord injury. There are also the terms "spinal cord injury" and "traumatic disease of the spinal cord". If the first concept denotes, first of all, the changes that occurred at the time of damage, the second describes the whole complex of developed pathologies, including secondary ones.

Such a pathology can affect any of the sections of the spine in which the spinal canal passes with the spinal cord:

• cervical;
• chest;
• lumbar.

The spinal cord is at risk of injury at any point

Classification of spinal injuries

There are several principles for classifying spinal cord injuries. According to the nature of the damage, they are:

• closed - not affecting the soft tissues located nearby;
• open:
  • without penetration into the spinal canal;
  • penetrating:
    • tangents;
    • the blind;
    • through.

Factors that provoked damage are of considerable importance in further therapy.. According to their nature and impact, the following categories of injuries are distinguished:

• isolated, caused by point mechanical influence;
• combined, accompanied by damage to other tissues of the body;
• combined, arising under the influence of toxic, thermal, wave factors.

The choice of treatment depends on the nature of the injury.

The nosological classification is based on a detailed description of the affected tissues, types of lesions and characteristic symptoms. In her system, the following types of damage are indicated:

• injury to supporting and protective components:
  • dislocation of the spine;
  • vertebral fracture;
  • fracture-dislocation;
  • ligament rupture;
  • spinal injury;
• nerve injury:
  • spinal cord injury;
  • shake;
  • contusion;
  • compression (compression);
    • acute - occurs in a short time;
    • subacute - formed a few days or weeks;
    • chronic - develops over months or years;
  • rupture (break) of the brain;
  • hemorrhage:
    • in the brain tissue (hematomyelia);
    • between shells;
  • damage to large vessels (traumatic infarction);
  • nerve root injury:
    • pinching;
    • gap;
    • injury.

Causes and development factors

The causes of spinal cord injury can be divided into three categories:

• traumatic - a variety of mechanical effects that provoke tissue destruction:
  • fractures;
  • dislocations;
  • hemorrhages;
  • bruises;
  • squeezing;
  • concussions;
• pathological - changes in tissues caused by disease states:
  • tumors;
  • infectious diseases;
  • circulatory disorders;
• congenital - anomalies of intrauterine development and hereditary pathologies.

Traumatic injuries are the most common category, occurring in 30–50 cases per 1 million inhabitants. Most of the injuries occur in able-bodied men aged 20–45 years.

Tumor changes are a common cause of pathological lesions of the spinal cord.

Characteristic symptoms and signs of damage to various parts of the spinal cord

The symptoms of a spinal cord injury do not develop instantly; they change over time. Primary manifestations are associated with the destruction of part of the nerve cells at the time of injury. Subsequent mass deaths can occur for a number of reasons:

• self-destruction (apoptosis) of damaged tissues;
• oxygen starvation;
• nutrient deficiency;
• accumulation of toxic decay products.

Increasing changes divide the course of the disease into five periods:

1. Acute - up to 3 days after injury.
2. Early - up to 3 weeks.
3. Intermediate - up to 3 months
4. Late - several years after the injury.
5. Residual - long-term consequences.

In the initial periods, the symptoms are shifted towards neurological symptoms (paralysis, loss of sensitivity), at the last stages - towards organic changes (dystrophy, tissue necrosis). Exceptions are concussions, which are characterized by a rapid course, and sluggish chronic diseases. Causes, location and severity of injury have a direct impact on the set of likely symptoms..

Loss of sensation and motor activity directly depends on the location of the injury

Table: symptoms of spinal cord injuries

Type of damage	Department of the spine
	Cervical	thoracic	Lumbar
Spinal nerve root injury	sharp pain in the area back of the head, shoulder blades; numbness of the skin and muscles; hand dysmotility.	pain in the back and intercostal space, aggravated by sudden movements; stabbing pain radiating to the heart.	sharp pain (sciatica) in the lower back, buttocks, hips; numbness and weakness in the limb; in men - violation of sexual function; impaired control of urination and defecation.
spinal cord injury	swelling in the neck; loss of sensation in the neck, shoulders and arms; weakening of the motility of the neck and hands; in case of severe trauma - impaired visual and auditory perception, weakening of memory.	swelling and numbness at the point of injury; pain: in back; in the heart; dysfunction: digestive; urinary; respiratory.	slight numbness at the site of injury; pain when standing or sitting; numbness and atrophy of the lower extremities.
Shake	General symptoms: violation of sensitivity at the site of injury; manifestations occur immediately after the moment of injury, last from several hours to several days.
	weakness and slight paralysis of the arms	shortness of breath	slight paralysis of the legs; violation of urination.
squeezing	discomfort in the area of ​​injury: loss of sensation; pain; burning - in chronic course; muscle weakness (paresis); spasms; paralysis.
Contusion	recurring muscle weakness; temporary paralysis; violation of reflexes; manifestations of spinal shock: system anomalies: increase or decrease in body temperature; excessive sweating; disturbances in the work of internal organs, including the heart; hypertension; bradycardia. Signs reach their maximum severity a few hours after the injury.
fracture	spasms of the neck muscles; difficult turning of the head; limitation of mobility and sensitivity of the body below the neck; paresis; paralysis; spinal shock.	pain: at the point of injury; shingles; in a stomach; when moving; violation: digestion; urination; loss of sensation and motor activity of the lower extremities; spinal shock.
Dislocation	the neck is unnaturally inclined; pain: head; at the point of injury; weakness; dizziness; loss of sensation; paralysis.	pain radiating to the intercostal space; paralysis of the lower extremities; paresis; violation: digestion; respiratory functions.	pain radiating to the legs, buttocks, abdomen; paresis or paralysis of the muscles of the lower extremities; loss of sensation in the lower body.
Complete rupture of the spinal cord	Rare pathology. Signs: severe pain at the site of injury; complete, irreversible loss of sensation and motor activity in a part of the body located below the break point.

Diagnosis of spinal cord injuries

Diagnosis of spinal cord injuries begins with clarification of the circumstances of the incident. During the interview of the victim or witnesses, primary neurological symptoms are established:

• motor activity in the first minutes after injury;
• manifestations of spinal shock;
• paralysis.

After delivery to the hospital, a detailed external examination with palpation is performed. At this stage, the patient's complaints are described:

• intensity and location of the pain syndrome;
• memory and perception disorders;
• change in skin sensitivity.

Palpation reveals displacement of bones, swelling of tissues, unnatural muscle tension, and various deformations. Neurological examination reveals changes in reflexes.

Accurate diagnosis requires the use of instrumental techniques. These include:

• computed tomography (CT);
• magnetic resonance imaging (MRI);
• spondylography - X-ray examination of bone tissue. Performed in various projections:
  • front;
  • side;
  • oblique;
  • through an open mouth;
• myelography - radiography using a contrast agent. Varieties:
  • ascending;
  • descending
  • CT myelography;
• study of somatosensory evoked potentials (SSEP) - allows you to measure the conductivity of the nervous tissue;
• vertebral angiography - a technique for examining blood vessels that feed the brain tissue;
• electroneuromyography is a method that allows you to assess the condition of muscles and nerve endings:
  • superficial;
  • needle;
• lumbar puncture with liquorodynamic tests - a method for studying the composition of the cerebrospinal fluid.

The MRI method allows you to quickly identify changes in organs and tissues

The applied diagnostic techniques allow to differentiate different types of spinal cord injuries among themselves, depending on their severity and causes. The result obtained directly affects the tactics of further therapy.

Treatment

Given the exceptional threat of spinal cord injuries to human life, all measures to save the victim are strictly regulated. Therapeutic measures are carried out by the efforts of medical personnel. Persons without special education can only provide the necessary first aid and only with a clear awareness of the actions performed.

First aid

Even with a slight suspicion of a spinal cord injury, first aid is as thorough as with a proven fact of injury. In the worst-case scenario, the greatest risk to the victim is fragments of destroyed vertebrae. Displaced in motion, bone fragments can irreversibly damage the spinal cord and the vessels that feed it. To prevent such an outcome, the victim's spine must be immobilized (immobilized). All actions must be carried out by a group of 3-5 people, acting carefully and in synchrony. The patient should be placed on the stretcher quickly, but smoothly, without sudden jerks, lifting only a few centimeters above the surface.

It should be noted that the stretcher for transporting the victim is placed under it. Carrying a non-immobilized patient, even for short distances, is strictly prohibited.

The method of immobilization depends on the point of injury. A person with injuries in the cervical region is placed on a stretcher face up, after fixing his neck with:

• a circle of soft fabric or cotton wool;
• Elansky tires;
• tires Kendrick;
• Shants collar.

Injuries to the thoracic or lumbar regions force the victim to be transported on a shield or hard stretcher. In this case, the body should be in a prone position on the stomach, a dense roller is placed under the head and shoulders.

A person with a damaged spine can be transported in a prone position: on the stomach (a) and on the back (b)

With the development of spinal shock, it may be necessary to normalize cardiac activity with atropine or dopamine. A strong pain syndrome involves the introduction of analgesics (Ketanov, Promedol, Fentanyl). Salt solutions and their derivatives (Hemodez, Reopoliglyukin) are used for heavy bleeding. Broad-spectrum antibiotics (Ampicillin, Streptomycin, Ceftriaxone) are needed to prevent infection.

If necessary, to save the life of the victim at the scene, the following can be carried out:

• cleaning the oral cavity from foreign bodies;
• artificial ventilation of the lungs;
• indirect heart massage.

After providing emergency care, the patient should be immediately taken to the nearest neurosurgical facility. It is strictly prohibited:

• transport the victim in a sitting or lying position;
• in any way affect the site of injury.

Inpatient treatment for bruises, concussions and other types of injuries

A set of therapeutic measures depends on the nature and severity of the injury. Light injuries - bruises and concussions - provide only drug therapy. Other types of injuries are treated in combination. In some situations that threaten irreversible changes in the tissues of the spinal cord, an emergency surgical intervention is required - no later than 8 hours after the moment of injury. Such cases include:

• deformation of the spinal canal;
• compression of the spinal cord;
• compression of the main vessel;
• hematomyelia.

It should be borne in mind that extensive internal injuries can endanger the patient's life during the operation. Therefore, in the presence of the following pathologies, immediate surgical intervention is contraindicated:

• anemia;
• internal bleeding;
• fat embolism;
• failure:
  • hepatic;
  • renal;
  • cardiovascular;
• peritonitis;
• penetrating chest injury;
• severe trauma to the skull;
• shock:
  • hemorrhagic;
  • traumatic.

Medical therapy

Drug treatment continues the tactics begun in the provision of first aid: the fight against pain, infections, cardiovascular manifestations. In addition, measures are being taken to preserve the affected brain tissue.

1. Methylprednisolone increases metabolism in nerve cells, enhances microcirculation processes.
2. Seduxen and Relanium reduce the sensitivity of affected tissues to oxygen starvation.
3. Magnesium sulfate allows you to control the balance of calcium, therefore - normalizes the passage of nerve impulses.
4. Vitamin E acts as an antioxidant.
5. Anticoagulants (Fraxiparine) are prescribed for the prevention of thrombosis, the risk of which increases with prolonged immobility of the limbs in spinal cord injuries.
6. Muscle relaxants (Baclofen. Mydocalm) relieve muscle spasms.

Photo gallery of medicines

Baclofen relieves muscle spasms Vitamin E is a powerful antioxidant. Methylprednisolone enhances microcirculation processes. Seduxen reduces the sensitivity of affected tissues to oxygen starvation Magnesium sulfate normalizes the passage of nerve impulses Fraxiparine is prescribed for the prevention of thrombosis

Decompression when squeezing the spinal cord

Most often, the greatest threat to the victim is not considered direct damage to the spinal cord, but its compression by surrounding tissues. This phenomenon - compression - occurs at the time of injury, further intensifying due to pathological changes. It is the reduction of pressure on the spinal cord (decompression) that is the primary goal of therapy. In 80% of cases, skeletal traction is successfully used for this.

Traction fixation reduces pressure on the spine

Surgical decompression is performed by direct access to the spine:

• anterior (pretracheal) - in case of cervical injury;
• anterolateral (retroperitoneal) - in case of damage to the lumbar vertebrae;
• side;
• back.

Vertebrae may be subject to:

• repositions - comparison of bone fragments;
• cornorectomy - removal of the vertebral body;
• laminectomy - removal of the arc or processes;
• discectomy - removal of intervertebral discs.

At the same time, normal innervation and blood supply to the affected area is restored. Upon completion of this, the spine is stabilized with a bone autograft or a metal implant. The wound is closed, the damaged area is immovably fixed.

Metal implants stabilize the spine after surgery

Video: spinal fracture surgery

Rehabilitation

The rehabilitation period after a spinal cord injury can last from several weeks to two years, depending on the extent of the injury. For successful recovery, it is necessary to preserve the relative integrity of the spinal cord - with a complete break, the regeneration process is impossible. In other cases, the growth of nerve cells occurs at a rate of about 1 mm per day. Rehabilitation procedures have the following goals:

• increased blood microcirculation in damaged areas;
• facilitating the delivery of medicines to the centers of regeneration;
• stimulation of cell division;
• preventing muscle dystrophy;
• improvement of the psycho-emotional state of the patient.

Proper nutrition

The basis of rehabilitation is a sustainable regimen and proper nutrition. The patient's diet should include:

• chondroprotectors (jelly, sea fish);
• protein products (meat, liver, eggs);
• vegetable fats (olive oil);
• fermented milk products (kefir, cottage cheese);
• vitamins:
  • A (carrot, pumpkin, spinach);
  • B (meat, milk, eggs);
  • C (citrus fruits, rose hips);
  • D (seafood, kefir, cheese).

Exercise therapy and massage

Therapeutic exercise and massage are focused on relieving spasms, improving muscle trophism, activating tissue metabolism and increasing spinal mobility.

Exercises should be started by the patient when his condition is stable, immediately after the removal of restrictive structures (gypsum, bandages, skeletal traction). Preliminary radiography of the damaged spine is a prerequisite for this stage.

Loads during exercise therapy increase in steps: the first two weeks are characterized by minimal effort, the next four - increased, during the last two exercises are performed while standing.

An example set is as follows:

Massage is an ancient and effective method of rehabilitation for back injuries. Given the sensitivity of the weakened spine, such mechanical actions should be performed by a person with knowledge and experience in the field of manual therapy.

Other physiotherapy techniques for recovery from injury

In addition, a variety of physiotherapeutic methods are widely used for the rehabilitation of the victim:

• hydrokinesitherapy - gymnastics in the aquatic environment;
• acupuncture - a combination of acupuncture techniques with exposure to weak electrical impulses;
• iontophoresis and electrophoresis - methods for delivering drugs to tissues directly through the skin;
• mechanotherapy - methods of rehabilitation involving the use of simulators;
• electrical nerve stimulation - restoration of nerve conductivity with the help of weak electrical impulses.

The aquatic environment creates supportive conditions for the injured spine, thereby accelerating rehabilitation

The psychological discomfort that arises in the victim due to forced immobility and isolation is helped to overcome by an ergotherapist - a specialist who combines the features of a rehabilitation therapist, psychologist and teacher. It is his participation that can restore the patient's lost hope and good spirits, which in itself significantly speeds up recovery.

Video: Dr. Bubnovsky about rehabilitation after spinal cord injuries

Treatment prognosis and possible complications

The prognosis of treatment depends entirely on the extent of the damage. Light injuries do not affect a large number of cells. Lost nerve circuits are quickly compensated for by free connections, so that their restoration occurs quickly and without consequences. Extensive organic damage is dangerous for the life of the victim from the first moment of its existence, and the prognosis for their treatment is ambiguous or even disappointing.

The risk of complications greatly increases without providing the necessary medical care in the shortest possible time.

Extensive damage to the spinal cord threatens with many consequences:

• violation of the conduction of nerve fibers due to rupture or hemorrhage (hematomyelia):
  • spinal shock;
  • violation of thermoregulation;
  • excessive sweating;
  • loss of sensation;
  • paresis;
  • paralysis;
  • necrosis;
  • trophic ulcers;
  • hemorrhagic cystitis;
  • hard tissue swelling;
  • sexual dysfunction;
  • muscle atrophy;
• spinal cord infection:
  • epiduritis;
  • meningomyelitis;
  • arachnoiditis;
  • abscess.

Prevention

There are no specific measures to prevent spinal cord injury. You can simply limit yourself to caring for your body, maintaining it in proper physical shape, avoiding excessive physical exertion, shocks, shocks, and collisions. Scheduled examinations by a specialist therapist will help to identify hidden pathologies that threaten the health of the back.